tinnitus and hyperacusis
debatable how old is old. In our research, patients over the age of 60 yrs were
classified in geriatric group. This is chosen to be consistent with the age at
which hearing loss tends to become sufficient to start producing problems in
everyday life (Davis 1989;
Agrawal et al. 2008).
and hyperacusis disability and handicap are related to activity limitations
(e.g. problems with sleep, concentration and hearing) and participation
restrictions caused by these symptoms (e.g. withdrawal from social situations,
problems at work and relationship difficulties) and their impact on the
individual’s psychological wellbeing and health-related quality of life (WHO 1999). Factors related to tinnitus and hyperacusis
handicap may be different for older populations because the odds of hearing
impairment, insomnia, anxiety, depression, cognitive and physical decline, and
reduced self-perceived health-related quality of life increase with increasing
age (Davis 1989;
Dawes et al. 2014; McCall 2004; Lenze & Wetherell 2011). It is important to explore the factors
associated with tinnitus and hyperacusis handicap in order to design
appropriate rehabilitative interventions, since “cures” for these conditions
are currently not available (Tyler &
Baker 1983). Recent research by Dr.Aazh’s tinnitus team assessed
tinnitus and hyperacusis handicap and factors associated with them for older
patients. The key findings are summarised below:
Do older patients get less
benefit from CBT specialised for Tinnitus and/or Hyperacusis
patients ask if there is an optimum age to receive therapy for tinnitus and/or
hyperacusis. Often older patients may be reluctant to undergo treatment as they
may think it is too late for achieving considerable improvement due to their
age (Aazh &
Moore 2018b). Dr. Aazh’s tinnitus team explored the
relationship between the changes in tinnitus handicap as measured via Tinnitus
Handicap Inventory (THI) (Newman et al. 1996) before and after audiologist-delivered CBT
and age in over 500 patients. As shown in the scatter plots, there was no
statistically significant correlation between the change in THI following
treatment and age (r=-0.04, p=0.33). This highlights that regardless of the age,
patients may benefit from the treatment.
tinnitus team also explored the relationship between the changes in hyperacusis
handicap as measured via Hyperacusis Questionnaire (HQ) (Khalfa et al.
2002) before and after audiologist-delivered CBT
and age in over 500 patients. Their results showed no statistically significant
correlation between the change in HQ following treatment and age (r=-0.01, p=0.82) (shown in the scatter plot). So it is important to
highlight that patients may benefit from the treatment regardless of their age.
Should we use hearing aids to minimise
Despite the high prevalence of tinnitus among
patients with hearing loss and vice versa, our result did not show a
significant relationship between the pure tone audiogram and THI in patients
over the age of 60. This outcome is consistent with previous studies which did
not have a focus on older patients (Gomaa et al.
2014; Hu et al. 2015; Ratnayake et al. 2009). Nevertheless, when older patients complain
of tinnitus, their hearing should be assessed, as recommended by the UK Good
Practice Guide (Department of
Health 2009) on the provision of services for adults with
tinnitus and the Clinical Practice Guideline for Tinnitus of the American
Academy of Otolaryngology - Head and Neck Surgery (Tunkel et al.
2014). Fitting of hearing aids to address hearing
impairment may or may not reduce the tinnitus handicap. In a study that
assessed patients’ perspectives on the effectiveness of various clinical
interventions in the management of tinnitus and hyperacusis (Aazh et al.
2016), use of hearing aids was rated as ineffective
by 36% of patients, and all of those who reported that hearing aids were
effective also reported that the counselling component of their treatment was
effective in the management of their tinnitus or hyperacusis (see the bar
diagram). Therefore, it is difficult to determine whether the hearing aids were
an effective component of the treatment package.
What are the key factors related to tinnitus handicap? “Tinnitus loudness
vs. Tinnitus Annoyance”
are conflicting results concerning the relationship between tinnitus loudness
and tinnitus handicap. Some authors reported no relationship (Folmer et al.
1999; Meikle et al. 1984; Hiller & Goebel 2007) and some reported a significant relationship (Tyler et al.
2014; Probst et al. 2016; Hiller & Goebel 2006). In our study, there was a significant
correlation between tinnitus loudness and THI score, but tinnitus loudness as
measured via Visual Analogue Scale (VAS) did not predict tinnitus handicap in
the multiple-regression model, while tinnitus annoyance as measured via VAS did.
This highlights the relevance of audiologist-delivered CBT for tinnitus (Aazh &
Allott 2016; Aazh & Moore 2018b; Aazh & Moore 2018a). During CBT, specialist audiologist uses
careful questioning and empathic listening skills in order to help the patient
to explore the underlying mechanism in which tinnitus produces annoyance and
help them to modify that.
Is insomnia in older patients related to tinnitus or to depression?
study on 151 tinnitus patients age>60 years, a multiple linear-regression
model showed that higher scores on the insomnia severity index (ISI) (Bastien et al. 2001) were associated with higher
(worse) scores on the depression subscale of the Hospital Anxiety and
Depression Scale (HADS) (Zigmond & Snaith 1983) (p=0.007). A 1-point increase in the mean HADS score for depression
was associated with an increase in ISI score of 0.46 (95% CI: 0.13 to 0.79).
This model explained 32% of the variance in the total ISI scores. As shown by
the regression model in Table, scores for the ISI were not predicted by VAS
scores for tinnitus loudness (p =
0.15), VAS scores for tinnitus annoyance (p= 0.6), scores for the anxiety subscale of the HADS (p = 0.6) or THI scores (p= 0.053).
Outcome of the
multiple regression model for predicting insomnia as measured via the Insomnia
Severity Index (ISI)
VAS (Tinnitus loudness)
VAS (Tinnitus annoyance)
VAS (Effect on life)
VAS = visual analogue
scale, HADS = hospital anxiety and depression scale, THI = tinnitus handicap
As shown in the scatter plot, insomnia in
older people was significantly predicted by depression scores in our study. It
is known that depression is more prevalent in older than in younger people (Mirowsky &
Ross 1992). A relationship between depression and
insomnia in older people has been suggested by several researchers (Foley et al.
1995; McCall 2004). If insomnia does not contribute directly to
tinnitus handicap in older people, then it may not be necessary to address
insomnia in the context of tinnitus rehabilitation. Perhaps insomnia needs to
be assessed and managed independently from tinnitus in conjunction with
treatment for depression. It is unlikely that using distractions sounds
generated via bedside sound generators offer a reliable solution for insomnia
in older tinnitus patients.
What are the factors
related to hyperacusis handicap in older patients?
study in patients over the age of 60 with tinnitus and/or hyperacusis showed
that depression as measured via the HADS was the main predictor of hyperacusis
handicap as measured via the HQ for an older population (see the table for
regression model). This highlights the need for psychological assessment in
older patients who experience hyperacusis. The scatter plot illustrates a more recent
analysis by Dr.Aazh’s tinnitus team on the relationship between depression and
hyperacusis involving over 400 patients.
Regression model for
predicting hyperacusis handicap as measured via the Hyperacusis Questionnaire
Regression coefficient (b)
THI = tinnitus handicap
inventory, HADS = hospital anxiety and depression scale
Dr. Aazh’s pioneering study challenges the view proposed by the
eminent psychologist, Professor Aaron Beck, that patients’ adverse reactions to
ordinary sounds are directly dependent on their anxiety levels.
The hypothesis that hyperacusis is related to anxiety has
been suggested by several authors. For example, Lader et al.
(1967) compared the reactions of people with various
phobias and a normal control group to sequences of 1-kHz tones presented at a
level of 100 dB (the authors did not state whether the level was specified as
SPL or HL). The anxious group showed progressive increases in sweating,
suggesting an increase in anxiety produced by the sounds, while the control
group did not show such increases. Beck (1976) suggested that people with anxiety neurosis
do not discriminate between safe and non-safe stimuli. Rather, any sound may be
interpreted as a danger signal, leading to further anxiety.
regression analysis of our data suggested that anxiety does not directly lead to hyperacusis handicap; rather the
hyperacusis handicap is predicted by depression. This finding is not consistent
with the view that patients’ adverse reactions to ordinary sounds are directly
dependent on their anxiety levels. We are not aware of any study in the
literature that assessed whether anxiety directly predicts hyperacusis handicap
in any age group. It is known that anxiety symptoms may lead to depressive
symptoms with increasing age (Wetherell et
al. 2001; Lenze & Wetherell 2011). This may explain the significant role of
depression in predicting hyperacusis handicap shown in the current study.
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